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1 Fearon & Co S O L I C I T O R S ESTABLISHED 1825 Partners: A. J. Phillips & F. L. E. Nash MEDICAL NEGLIGENCE COMPENSATION QUESTIONNAIRE If you would like Fearon & Co to act for you in obtaining compensation for an accident you have been involved with then would you kindly complete, sign and date this Questionnaire and return it to us. A member of Fearon & Co.'s team will be in contact with you shortly to discuss your claim, to provide initial advice regarding it and concerning what further steps are necessary to be undertaken on your behalf. It is important that Fearon & Co. receive from you as much available information as possible in order to be in a position to advise you fully. When instructing Fearon & Co to act for you, do please remember that the Accident Compensation Unit within the firm comprises just one area of Fearon & Co's expertise, and that Fearon & Co also provides legal services in all key areas of law, including: Commercial Services - the acquisition and disposal of Commercial Property, Company and Business Law Litigation Services - Personal Injury claims, Matrimonial, Landlord and Tenant and all aspects involving civil dispute Private Client Services - sale and purchase of Residential Property, Wills, Probate and Inheritance Tax Planning KINDLY COMPLETE THIS QUESTIONNAIRE AND RETURN IT TO FEARON & CO. Westminster House 6 Faraday Road Guildford Surrey GU1 1EA Tel: +44 (0) Fax: +44 (0)

2 SECTION 1 - GENERAL INFORMATION (a) Full names: (b) Age and date of birth: (c) Home address: (d) Telephone number(s) Home: Work: Mobile: (e) address: (f) National Insurance No.: (g) Do you have any Accident, General Insurance, or other cover for legal expenses? If so, please provide a copy of your Policy. This cover may be afforded under your household contents insurance, buildings insurance, motor insurance, a perk through some credit card agreements or you may have paid an additional fee to have legal expenses insurance. If you are not a UK resident you may have cover under a travel insurance policy. It is important that you make a thorough search to establish whether or not you have this cover. If you do not have legal expenses insurance please sign and date on page 11 to acknowledge that you have checked and that you understand that you are responsible, not us, for any shortfall in your costs being awarded as a result of it transpiring that you did in fact have this cover in place. 2

3 SECTION 2 - THE ACCIDENT (a) Where did it happen? (b) When did it happen? (c) At what time did it happen? (d) Who was involved in the incident? (e) What are the names and addresses of the people involved? (f) On page 11 please provide an explanation of how the incident was caused, including the events leading up to the incident and the incident itself. Also, use this page to sketch a plan relating to the scene of the accident to the best of your ability indicating the relative positions of those persons and objects involved. 3

4 (g) What were you doing at the time? (h) Were there any witnesses to the incident and, if so, what are their names, addresses or possible contacts? (i) Was there any official involvement for instance, have the relevant Health Care Officials and/or The Medical Assocoation been notified. If so, please provide names, numbers, addresses etc. 4

5 SECTION 3 PLACE OF ACCIDENT (a) What are the names of those persons present at the scene of the accident and which of those persons was responsible for supervision? (b) If you were being supervised what was the nature and extent of that supervision? (c) Had any verbal or written health warnings been given to you relevant to the accident occasioned prior to or after the accident? Did you signed a disclaimer form? If so, please provide a copy of it. Where you told to take any safety precautions prior to or after the accident? If so, what were they and did you follow them? (d) Have there been any previous accidents or history of safety complaints relevant to the accident in question? (e) Was the accident reported to the relevant 5

6 medical practioner and/or his supervisor and relevant governing body? If so, then please provide dates and details. (f) What happened immediately after the accident (to include anything said by any persons at the time)? (g) Have any systems or procedures been changed as a result of the accident? (h) If the accident relates to the use of equipment in operation, please describe the equipment in question and explain how it was being used at the time of the accident: 6

7 SECTION 4 - THE INJURIES (a) What injuries have you suffered? (b) When did they become apparent? (c) What treatment have you had and for how long? (d) If you lost consciousness during the accident, for how long and exactly when? (f) Who treated you? In providing this information please give the full details, names and addresses of all relevant bills, Surgeons, Hospitals, and GPs treating you. (g) If you suffered external injuries 7

8 which are unlikely to give rise to long term scarring, do you have photographs available to record these? (h) What is the current status of any injury, what pain is it causing, what treatment have you had and are you disabled because of it? (i) If you are continuing to receive treatment, what is your view on the future of this condition and the view of any Medical Practitioner advising you? 8

9 SECTION 5 - EMPLOYMENT (a) How much time off work have you had as a direct result of the injury? (b) What is the name and address of your employer? (c) What were your earnings before the accident? (d) If you are incapacitated :- (j) what is your current ability to or prospects for work; (ii) what restrictions are there on your domestic or social life; (iii) have you been in touch with the Social Services and/or claimed any benefits in respect of any injury. 9

10 (e) Are you eligible for, or have you been paid, Statutory Sick Pay or Health Insurance by your employer? (f) Have you received any payment of wages or money in lieu of wages with right of recoupment? (g) Please provide details of any expenses resulting directly from the accident (special damages). (f) Have you suffered from any illnesses or disabilities in the past, having a bearing on the current position? 10

11 MY EXPLANATION OF FACTS AND CIRCUMSTANCES AS TO HOW THE INCIDENT WAS CAUSED (INCLUDING THE EVENT LEADING UP TO THE INCIDENT AND THE INCIDENT ITSELF) SIGN AND DATE BELOW Signed... Date... 11

A. J. Phillips PLACE OF WORK OR RECREATION ACCIDENT COMPENSATION QUESTIONNAIRE If you would like Fearon & Co to act for you in obtaining compensation for an accident you have been involved with then would

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